The health care environment—with its packed work days, demanding pace, time pressures, and emotional intensity—can put physicians and other clinicians at high risk for burnout. Burnout is a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment.

In recent years, the rising prevalence of burnout among clinicians (over 50 percent in some studies) has led to questions on how it affects access to care, patient safety, and care quality. Burned-out doctors are more likely to leave practice, which reduces patients’ access to and continuity of care. Burnout can also threaten patient safety and care quality when depersonalization leads to poor interactions with patients and when burned-out physicians suffer from impaired attention, memory, and executive function.

"This research on work conditions, clinician reactions (including satisfaction and burnout), and patient outcomes over the past 15 years has allowed us to make concrete recommendations to health systems on how to build healthier workplaces for providers and patients."

Mark Linzer, M.D.Hennepin County Medical Center, Minneapolis, MN

Since 2001, AHRQ has been investing in major projects that examine the effects of working conditions on health care professionals’ ability to keep patients safe while providing high-quality care. This research is part of the Agency’s ongoing efforts to develop evidence-based information aimed at improving the quality of the U.S. health care system by making care safer for patients and improving working conditions for clinicians.

Figure 1. Causes of clinician burnout

One AHRQ-funded project, the MEMO—Minimizing Error, Maximizing Outcome—Study (AHRQ grant HS11955), found that more than half of primary care physicians report feeling stressed because of time pressures and other work conditions. Researchers surveyed 422 family physicians and general internists who worked in 119 ambulatory care clinics and surveyed 1,795 patients from these clinics and reviewed their medical records for information on care quality and medical errors. More than half of the physicians reported experiencing time pressures when conducting physical examinations. Nearly a third felt they needed at least 50 percent more time than was allotted for this patient care function. In addition, nearly a quarter said they needed at least 50 percent more time for follow-up appointments.

Work conditions, such as time pressure, chaotic environments, low control over work pace, and unfavorable organizational culture, were strongly associated with physicians’ feelings of dissatisfaction, stress, burnout, and intent to leave the practice. However, physicians’ reactions to these work conditions were not consistently associated with quality of patient care. The investigators’ interpretation was that, although physicians are affected by work conditions, their reactions do not translate into poorer quality care because the physicians act as buffers between the work environment and patient care. When lower quality care was seen, the investigators found it was the organization that burned doctors out that led to lower quality care, rather than the burned-out doctors themselves.

The MEMO study also found that the hope that electronic health records (EHRs) in the workplace would reduce stress has not been realized; in fact, implementation of an EHR can contribute to burnout. Researchers found that practices that implemented electronic health records saw in increase in stress as EHR use matured and then a decrease, but stress did not return to the baseline. Additionally, fully mature EHR systems, especially with shorter visits, were associated with physician stress, burnout, and intent to leave the practice. Another study, MS Squared—Minimizing Stress, Maximizing Success of the EHR (AHRQ grant HS22065)—of 400 doctors is currently identifying the amount of EHR-related burnout in practices, EHR-related stressors, and solutions for mitigating this stress.

"Physician friendly" and "family friendly" organizational settings also seem to result in greater physician well-being, according to an AHRQ-funded study involving a national sample of 171,000 primary care doctors. Doctors also fare better in organizations where they are not compensated for individual productivity, are not under time stress, have more control over clinical issues, and are able to balance family life with their work. (AHRQ grant HS00032)

Interventions

Figure 2. Promising interventions for clinician burnout

AHRQ-funded research led to a new measure of burnout and the identification of several interventions that can potentially mitigate it. AHRQ grantee Mark Linzer, M.D., FACP, of Hennepin County Medical Center in Minneapolis, MN, created the Mini Z Burnout Survey that lets practices take a quick temperature of how much stress and burnout they are experiencing and what might be causing it. Linzer’s work is included in the American Medical Association’s Steps Forward evidence-based module on burnout prevention for doctors and practices, created by Hennepin, the American Medical Association, and the American College of Physicians.

The AHRQ-funded Healthy Work Place Study (AHRQ grant HS18160), a cluster randomized trial of 166 physicians, nurse practitioners, and physician assistants in 34 primary care clinics, had clinicians select from a list of interventions from three categories that addressed improving communication, changing workflow, or addressing clinician concerns via quality improvement projects. Each of these categories of interventions led to improvements in some clinician outcomes, suggesting that a range of interventions that directly address clinicians’ perceptions and concerns can be effective.

Some of the interventions on the list included—

Scheduling monthly provider meetings focused on work life issues or clinical topics after surveying staff members on which topics to address.

Enhancing team functioning through diabetes and depression screening quality improvement projects to engage office staff, enhance team work, and reduce the pressure on physicians to be responsible for all aspects of care.

Having medical assistants enter patient data into electronic health records, track forms, and send faxes to give doctors more face-to-face time with patients.

Implementing a Patient-Centered Medical Home can also improve physician satisfaction and reduce burnout. An AHRQ study of 26 clinics in a health system found that reducing the physician panel size to 1,800 patients, increasing flexibility for longer patient visits, reducing the number of face-to-face visits per day, and increasing care team staffing improved work satisfaction and burnout rates. The percentage of staff reporting that they were “extremely satisfied” with their workplace increased from 38.5 percent at baseline to 42.2 percent at follow up, and rates of reported burnout decreased from 32.7 to 25.8 percent after implementing the Patient-Centered Medical Home. (AHRQ grant HS19129)

Additional interventions that need further testing but may be able to assist in reducing burnout are—

Creating standing order sets.

Providing responsive information technology support.

Reducing required activities.

Providing time in the workday and workflow to complete required documentation tasks and enter data into the electronic health record.

Offering flexible or part-time work schedules.

Having leaders model and support work-home balance.

Hiring floating clinicians to cover unexpected leave.

Building workplace teams that address work flow and quality measures.

Ensuring values align between clinicians and leaders.

Finally, AHRQ’s EvidenceNOW: Advancing Heart Health in Primary Care initiative is studying how best to provide external quality improvement support to small- and medium-sized primary care practices to advance heart heath, while also building the capacity of primary care practices to incorporate evidence into care delivery. Recent preliminary findings from ESCALATES, the EvidenceNOW national evaluator, indicate that more than one quarter of the physicians in the small- and medium-sized primary care practices participating in EvidenceNOW are experiencing moderate to severe levels of burnout. In addition, more than 20 percent of nurse practitioners, physician assistants, and other clinical staff reported being burned out. Of note, rural clinicians reported the highest rates of burnout. Through tailored practice facilitation that responds to the needs and challenges of individual practices, EvidenceNOW is working to increase primary care professionals’ workplace satisfaction and to reduce levels of burnout. Early findings from across the EvidenceNOW cooperatives suggest that EvidenceNOW interventions are having a positive impact and creating healthier workplaces.

Conclusion

Burnout takes a toll on physicians, their patients, and their practices. Short visits, complicated patients, lack of control, electronic health record stress, and poor work-home balance can lead to physicians leaving practices they once loved, poor patient outcomes, and shortages in primary care physicians. AHRQ’s extensive body of research findings clearly demonstrate what causes burnout and offers a starting point for interventions on how it can be reversed.

More Information

For more information on this topic, visit AHRQ.gov and search "burnout."